healthcare surge capacity in disasters adapted from a presentation by john l. hick, md. used with...
TRANSCRIPT
Healthcare Surge Healthcare Surge Capacity in Capacity in DisastersDisasters
Adapted from a presentation by Adapted from a presentation by John L. Hick, MD. Used with John L. Hick, MD. Used with permissionpermission
Barbara Barbara DodgeDodgeVirginia Virginia HelgetHelgetSharon Sharon MedcalfMedcalf
OverviewOverview Section 1 – Incidents and Incident Section 1 – Incidents and Incident
ManagementManagement
Section 2 – Healthcare Facility and Section 2 – Healthcare Facility and Community Surge Community Surge
Section 3 – Selected Surge Section 3 – Selected Surge Situations and Special TopicsSituations and Special Topics
Section 1: Section 1: Incidents and Incidents and Incident Incident ManagementManagement
OverviewOverview
Define disasterDefine disaster Incident management and its Incident management and its
importance in surge capacityimportance in surge capacity The CST of surgeThe CST of surge Getting all C’s – Command, control, Getting all C’s – Command, control,
communications and coordinationcommunications and coordination
What is a disaster?What is a disaster? Demand for resources acutely Demand for resources acutely
outstrips supplyoutstrips supply May depend on day / time / facilityMay depend on day / time / facility Internal / External eventsInternal / External events Static vs. dynamic - timelineStatic vs. dynamic - timeline
Contagious events special sub-categoryContagious events special sub-category ‘‘Complex Incidents’Complex Incidents’
Key goal of planning and Key goal of planning and incident management:incident management:
Get the…Get the… RightRight resourcesresources…to the…to the RightRight placeplace…at the…at the RightRight timetime…to prevent…to prevent A ‘special incident’ from becoming A ‘special incident’ from becoming
a…a…
DISASTERDISASTER
Disasters – Reality Disasters – Reality CheckCheck Only 7 disasters in U.S. history have Only 7 disasters in U.S. history have
resulted in > 1000 fatalitiesresulted in > 1000 fatalities Only 10-15 incidents per year result Only 10-15 incidents per year result
in more than 40 injured victimsin more than 40 injured victims
Historic DisastersHistoric Disasters
1865 Steamship explosion1865 Steamship explosion 1,547 deaths1,547 deaths 1871 Peshtigo, WI fire1871 Peshtigo, WI fire 1,1821,182 1889 Jonestown, PA flood 1889 Jonestown, PA flood > 2,200 > 2,200 1904 Steamship fire, NYC 1904 Steamship fire, NYC 1,0211,021 1928 FL Okeechobee Hurricane 2,0001928 FL Okeechobee Hurricane 2,000 2001 NYC WTC disaster2001 NYC WTC disaster 2,795 2,795
(inexact)(inexact) 2005 Hurricane Katrina 2005 Hurricane Katrina 1697 1697
(inexact)(inexact)
Cap
ab
ilit
ies
and
Res
ou
rces
Federal Response
Regional / Mutual Response Systems
State Response
Increasing magnitude and severity
Local Response, Municipal and County
Tiered Response StrategyTiered Response Strategy
Minimal Low Medium High Catastrophic
Now, Now,
let’s think about let’s think about
PlanningPlanning
What is most likely?What is most likely?
Moderate sized disasterModerate sized disaster > 120 injured is threshold for chaos> 120 injured is threshold for chaos Plan for 50-150 victims Plan for 50-150 victims Tie planning to Hazard Vulnerability Tie planning to Hazard Vulnerability
AnalysisAnalysis
Planning DocumentsPlanning Documents
Hazard Vulnerability Hazard Vulnerability AnalysisAnalysis
Emergency Management Emergency Management PlanPlan
Emergency Operations PlanEmergency Operations Plan Departmental PlansDepartmental Plans
CHRISTUS Spohn Hospital South
HAZARD AND VULNERABILITY ASSESSMENT TOOLEVENTS INVOLVING HAZARDOUS MATERIALS
SEVERITY = (MAGNITUDE - MITIGATION)
EVENTPROBABILITY HUMAN
IMPACTPROPERTY
IMPACTBUSINESS
IMPACTPREPARED-
NESSINTERNAL
RESPONSEEXTERNAL RESPONSE
RISK
Likelihood this will occur
Possibility of death or injury
Physical losses and damages
Interuption of services
PreplanningTime,
effectivness, resouces
Community/ Mutual Aid staff
and suppliesRelative threat*
SCORE
0 = N/A 1 = Low 2 = Moderate 3 = High
0 = N/A 1 = Low 2 = Moderate 3 = High
0 = N/A 1 = Low 2 = Moderate 3 = High
0 = N/A 1 = Low 2 = Moderate 3 = High
0 = N/A 1 = High
2 = Moderate 3 = Low or none
0 = N/A 1 = High
2 = Moderate 3 = Low or none
0 = N/A 1 = High
2 = Moderate 3 = Low or none
0 - 100%
Mass Casualty Hazmat Incident (From historic events at your MC with >= 5 victims)
1 2 1 2 1 2 1 17%
Small Casualty Hazmat Incident (From historic events at your MC with < 5 victims)
2 2 1 2 1 1 1 30%
Chemical Exposure, External
1 2 1 1 1 1 1 13%
Small-Medium Sized Internal Spill
1 1 1 1 2 2 1 15%
Large Internal Spill 1 1 1 1 2 2 1 15%
Terrorism, Chemical2 2 1 2 1 1 1 30%
Radiologic Exposure, Internal
1 1 1 1 2 2 2 17%
Radiologic Exposure, External
1 1 1 1 2 2 1 15%
Terrorism, Radiologic
1 1 1 1 2 2 1 15%
AVERAGE 1.22 1.44 1.00 1.33 1.56 1.67 1.11 18%
*Threat increases with percentage.
11RISK = PROBABILITY * SEVERITY
73 0.18 0.41 0.45
What is Surge What is Surge Capacity?Capacity?
Surge Capacity C S TSurge Capacity C S T
The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication
ss CoordinationCoordination
* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’
The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial
The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport
CommandCommand
What is Incident Command?What is Incident Command? Incident Management SystemIncident Management System Multi-agency Coordination SystemMulti-agency Coordination System Public Information SystemsPublic Information Systems
Standard languageStandard language Standardized job dutiesStandardized job duties Scalable and flexibleScalable and flexible
Basic HICS Basic HICS StructureStructure
INCIDENT COMMANDER
LIAISONOFFICER
SAFETY OFFICER
PUBLIC INFORMATIONOFFICER
LOGISTICSSECTION
PLANNINGSECTION
FINANCESECTION
OPERATIONSSECTION
MEDICAL TECHNICALSPECIALIST
Tools in the new HICSTools in the new HICS
Job action sheetsJob action sheets Position recommendationsPosition recommendations Incident Planning GuidesIncident Planning Guides Incident Response GuidesIncident Response Guides Forms – consistent with FEMA Forms – consistent with FEMA
requirementsrequirements NIMS (compliance activities)NIMS (compliance activities)
Use it oftenUse it often Incident Command must be used Incident Command must be used
as frequently as possible (daily as frequently as possible (daily responses)responses)
Employee familiarity and comfort Employee familiarity and comfort with system is dependent on with system is dependent on exposure / practiceexposure / practice
Surge Capacity PartnersSurge Capacity Partners EMS EMS Emergency ManagementEmergency Management Public HealthPublic Health Public Safety/Law enforcementPublic Safety/Law enforcement Hospitals and Healthcare SystemsHospitals and Healthcare Systems American Red CrossAmerican Red Cross Behavioral healthBehavioral health Jurisdictional legal authoritiesJurisdictional legal authorities
Regional CoordinationRegional Coordination
Medical Response SystemsMedical Response Systems Trauma SystemTrauma System Public Health DistrictsPublic Health Districts Regional Hospital Resource Center Regional Hospital Resource Center
(RHRC)(RHRC) Multi-Agency CoordinationMulti-Agency Coordination
Federal AssetsFederal Assets
National Disaster Medical System National Disaster Medical System (NDMS)(NDMS)
Urban Search and Rescue (eg: Urban Search and Rescue (eg: Nebraska TF-1)Nebraska TF-1)
Commissioned Corps Readiness Commissioned Corps Readiness ForceForce
Military (NORTHCOM)Military (NORTHCOM) Federal Medical StationsFederal Medical Stations CDC SNS and VMICDC SNS and VMI
Section 2: Section 2: Healthcare Facility Healthcare Facility and Community and Community Surge Surge
OverviewOverview
Initial ActionsInitial Actions Facility-based surgeFacility-based surge
Space, staff, stuff, specialSpace, staff, stuff, special Triage, treatment, and transportTriage, treatment, and transport
Community-based surge capacityCommunity-based surge capacity Partners and playersPartners and players Alternate care sitesAlternate care sites
Capacity vs. CapabilityCapacity vs. Capability
Surge Capacity – ‘the ability to manage Surge Capacity – ‘the ability to manage increased patient care volume that increased patient care volume that otherwise would severely challenge or otherwise would severely challenge or exceed the existing medical infrastructure’exceed the existing medical infrastructure’
Surge Capability – ‘the ability to manage Surge Capability – ‘the ability to manage patients requiring unusual or very patients requiring unusual or very specialized medical evaluation and specialized medical evaluation and intervention, often for uncommon medical intervention, often for uncommon medical conditions’conditions’
Barbera and MacintyreBarbera and Macintyre
Initial Actions – Notification Initial Actions – Notification and Communicationand Communication Facility notified of event / recognizes eventFacility notified of event / recognizes event
AdvisoryAdvisory AlertAlert
Declaring an emergency – Declaring an emergency – ActivationActivation
Mobilize adequate resources based on intelMobilize adequate resources based on intel Plan for next operational period (action planning cycles)Plan for next operational period (action planning cycles)
Notifying Notifying StaffStaff Patients and their familiesPatients and their families General publicGeneral public
Ongoing communications / information cycleOngoing communications / information cycle
Different types of ‘surge’Different types of ‘surge’
Pre-event surge (eg: pandemic, Pre-event surge (eg: pandemic, hurricane)hurricane)
Healthcare facility-basedHealthcare facility-based DischargesDischarges AdmissionsAdmissions
Community-basedCommunity-based Ambulatory careAmbulatory care
Existing sitesExisting sites Field treatment sitesField treatment sites
Non-ambulatory care (acute care center / Non-ambulatory care (acute care center / off-site)off-site)
EMSEMS
Pre-event surge /actionsPre-event surge /actions
If short warning time present:If short warning time present: Determine what service lines will be Determine what service lines will be
maintainedmaintained Mobilize staff and resourcesMobilize staff and resources
If longer warning time:If longer warning time: Consider expanding services to take Consider expanding services to take
care of as much elective business as care of as much elective business as possible (eg; evening operative cases, possible (eg; evening operative cases, expanded clinic hours)expanded clinic hours)
Facility-based SurgeFacility-based Surge
Hospitals may use HRSA dollars to Hospitals may use HRSA dollars to purchase cots, lab equipment, and purchase cots, lab equipment, and other supplies other supplies
Nearly always preferred to off-siteNearly always preferred to off-site Comfort of staffComfort of staff ExpertiseExpertise
Off-site: designate what equipment Off-site: designate what equipment can be taken and who can operate can be taken and who can operate itit
Reality CheckReality Check
Very rare to be overwhelmed in a Very rare to be overwhelmed in a disasterdisaster
Only 6% of hospitals in 29 Only 6% of hospitals in 29 disasters experienced supply disasters experienced supply issues, and 2% had staffing issues, and 2% had staffing shortages . . . shortages . . .
Most had too many!Most had too many!
In the Real World . . .In the Real World . . .
At least 50% arrive self-referredAt least 50% arrive self-referred ‘‘Upside down triage’ – least Upside down triage’ – least
wounded arrive firstwounded arrive first On average, 67% of patients in any On average, 67% of patients in any
given disaster are cared for at the given disaster are cared for at the hospital nearest the event (range 41-hospital nearest the event (range 41-97%)97%)
Rule of ThumbRule of Thumb Per 100 patients injured:Per 100 patients injured:
25 dead at scene25 dead at scene 75 seek medical care75 seek medical care
63 minor63 minor 12 serious12 serious
‘‘Rule of 85/15%’ has applied to all Rule of 85/15%’ has applied to all disasters thus far inc NYC 9-11 disasters thus far inc NYC 9-11 (minor vs. serious)(minor vs. serious)
In every catastrophic disaster, In every catastrophic disaster, sustained pressure on the healthcare sustained pressure on the healthcare system is seen following the incidentsystem is seen following the incident
Critical Hospital Critical Hospital ResourcesResources Physical PlantPhysical Plant PersonnelPersonnel SupervisionSupervision Supplies and EquipmentSupplies and Equipment CommunicationCommunication TransportationTransportation
Koenig K et al. Acad Emerg Med 1996:3;723-Koenig K et al. Acad Emerg Med 1996:3;723-77
Surge Capacity C S TSurge Capacity C S T
The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication
ss CoordinationCoordination
* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’
The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial
The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport
SpaceSpace ED and clinic triage protocols (evolve with event)ED and clinic triage protocols (evolve with event) Discharges and transfers (eg: nursing home)Discharges and transfers (eg: nursing home)
Discharge holding areaDischarge holding area Treat patients in halls / flat space areas (cots)Treat patients in halls / flat space areas (cots) Cancel elective proceduresCancel elective procedures Convert procedure/OR/PACU areas to ICU spaceConvert procedure/OR/PACU areas to ICU space Accommodate vents on floor Accommodate vents on floor Alternative ambulatory care areas / triage areasAlternative ambulatory care areas / triage areas
SpaceSpace Don’t forget surge space for:Don’t forget surge space for:
Family members / Family support centerFamily members / Family support center Tracking system (badge)Tracking system (badge)
Media in separate spaceMedia in separate space Consider traffic patterns and satellite spaceConsider traffic patterns and satellite space
Behavioral health areaBehavioral health area Staff respiteStaff respite Labor poolLabor pool Staff housing / sleeping (family Staff housing / sleeping (family
members?)members?)
StaffStaff Different events = different staff Different events = different staff
needsneeds Eg: HAZMAT vs. trauma vs. Eg: HAZMAT vs. trauma vs.
monkeypoxmonkeypox Appropriate specialtiesAppropriate specialties
Scope of event = scope of staff call-inScope of event = scope of staff call-in Mechanism to reach staffMechanism to reach staff Obligations of the staffObligations of the staff
Contract staffContract staff What are they required to do?What are they required to do?
StaffStaff Assign staff to specific areas when Assign staff to specific areas when
possiblepossible Don’t forget the support staff Don’t forget the support staff Nursing staff often limiting factorNursing staff often limiting factor
Team nursingTeam nursing Involve family in careInvolve family in care
What do specialists “have” to do?What do specialists “have” to do? Staff extenders / Staff rolesStaff extenders / Staff roles
Mentoring and supervision of extra staffMentoring and supervision of extra staff Just in time trainingJust in time training
Staff AugmentationStaff Augmentation Hospital personnelHospital personnel Clinic personnelClinic personnel Medical Reserve CorpsMedical Reserve Corps Non-clinical practice professionalsNon-clinical practice professionals Retired professionals (eg: via Retired professionals (eg: via
Medical Society)Medical Society) Trainees in health professionsTrainees in health professions Civil Support Team, Civil Air PatrolCivil Support Team, Civil Air Patrol Lay public (CERT teams, etc)Lay public (CERT teams, etc) Federal / interstate personnelFederal / interstate personnel
StuffStuff
Provider protectionProvider protection General patient care suppliesGeneral patient care supplies Specialty patient care suppliesSpecialty patient care supplies Support suppliesSupport supplies
Stuff – Provider Stuff – Provider ProtectionProtection Personal Protective EquipmentPersonal Protective Equipment Medications – antidotes?, anti-virals?Medications – antidotes?, anti-virals? Consider:Consider:
re-usere-use duration of useduration of use other risk-reducing strategies (UV light, other risk-reducing strategies (UV light,
ventilation, etc)ventilation, etc)
Stuff – General Patient Stuff – General Patient CareCare Airway – disposable intubation blades, Airway – disposable intubation blades,
bag/masksbag/masks Surgical – chest tube traysSurgical – chest tube trays Medications – Morphine, Valium, Medications – Morphine, Valium,
AtropineAtropine Other disposables – catheters, Other disposables – catheters,
dressings, linensdressings, linens Durable – beds, vents, IV pumps, BP Durable – beds, vents, IV pumps, BP
cuffscuffs
Stuff – Specialty Patient Stuff – Specialty Patient CareCare Example – burnExample – burn
Adaptic dressings Adaptic dressings BacitracinBacitracin Kerlix dressingsKerlix dressings50% BSA burn needs 14 liters 50% BSA burn needs 14 liters
LR/NS in 1LR/NS in 1stst 24h, MS 24h, MS 250mg/24h)250mg/24h)
Persistent SBP < 90mmHg or age-appropriate hypotension unresponsive to fluids
Occasional hypotension or other signs of poor perfusion
No signs of shock
Laboratory or clinical evidence of multiple (> 4) organ system failure*
Laboratory evidence of 2-3 organ system failure
Respiratory failure only
Severe underlying disease with poor short-term prognosis**
Severe underlying disease with poor long-term prognosis and/or ongoing resource demand
No severe underlying disease
Long duration – ARDS, infectious causes of respiratory failure, (estimate > 7 days on ventilator)
Moderate duration – ARDS or infectious cause in healthy patient (estimate 3-7 days on ventilator)
Short duration – flash pulmonary edema, chest trauma, other anticipating < 3 days on ventilator
Worsening oxygenation index***
Stable oxygenation index over time (failure to improve after adequate disease-specific trial of mechanical ventilation)
Improving oxygenation index
Poor prognosis based upon epidemiology of specific disease (eg; pandemic influenza) for patient group.
Indeterminate / intermediate prognosis based upon epidemiology of specific disease process
Good prognosis based upon epidemiology of specific disease
High potential for death according to predictive model
Intermediate potential for death according to predictive model
Low potential for death according to predictive model
Ventilator re-allocated Patient keeps ventilator
Stuff – Support SuppliesStuff – Support Supplies
FoodFood WaterWater Office suppliesOffice supplies UtilitiesUtilities CommunicationsCommunications Oxygen supplyOxygen supply
Surge Capability / Surge Capability / SpecialtySpecialty BurnBurn Chemical / DecontaminationChemical / Decontamination IsolationIsolation PediatricPediatric Blast injury / mass traumaBlast injury / mass trauma Behavioral HealthBehavioral Health
Surge Capacity C S TSurge Capacity C S T
The 4 C’sThe 4 C’s CommandCommand ControlControl CommunicationCommunication
ss CoordinationCoordination
* Surge capacity * Surge capacity CANNOT occur if CANNOT occur if you don’t ‘get all you don’t ‘get all C’s’C’s’
The 4 S’sThe 4 S’s SpaceSpace StaffStaff StuffStuff SpecialSpecial
The 3 T’sThe 3 T’s TriageTriage TreatTreat TransportTransport
‘‘T’ - OperationsT’ - Operations
TriageTriage TreatmentTreatment TransportTransport
TriageTriage
Hospital triage: The most critical Hospital triage: The most critical patients firstpatients first
Mass Casualty triage: The greatest Mass Casualty triage: The greatest amount of good for the largest number amount of good for the largest number of people. Resources used on the victims of people. Resources used on the victims that have the best chance of survivalthat have the best chance of survival
TriageTriage
Location?Location? Triage officerTriage officer Triage tags / initial registration or Triage tags / initial registration or
trackingtracking Locations of care – where are patients Locations of care – where are patients
triaged TO?triaged TO? Key bottlenecks – decontamination, Key bottlenecks – decontamination,
radiology (eg; CT), transportation, OR, radiology (eg; CT), transportation, OR, ICUICU
TreatmentTreatment What patients may be safely treated in What patients may be safely treated in
what areas:what areas: ED, clinics, lobby areas, etcED, clinics, lobby areas, etc
Deal with life-threats only initiallyDeal with life-threats only initially Defer definitive wound closures, fracture Defer definitive wound closures, fracture
reductionsreductions Defer most xrays and labs until demand Defer most xrays and labs until demand
easeseases Use your clinical skills!Use your clinical skills! What is the expectation for What is the expectation for
documentation / nursing orders during documentation / nursing orders during disaster?disaster?
Transportation Transportation Capacity/CapabilityCapacity/Capability
TransportTransport
InternalInternal Transportation from ED to other in-hospital Transportation from ED to other in-hospital
locations (CT, OR, etc)locations (CT, OR, etc) Personnel and resources (beds and Personnel and resources (beds and
wheelchairs, etc)wheelchairs, etc) ExternalExternal
Transport resources – ground, rotor and Transport resources – ground, rotor and fixed wing, alternative ground (WC vans, etc)fixed wing, alternative ground (WC vans, etc)
Referral centers – what’s your backup when Referral centers – what’s your backup when usual partners are full / unable to receive?usual partners are full / unable to receive?
TransportTransport
EMS issuesEMS issues Few communities have adequate EMS Few communities have adequate EMS
resources resources Many EMS personnel have competing Many EMS personnel have competing
demands during disaster (fire demands during disaster (fire department, hospital, family) and may department, hospital, family) and may not be availablenot be available
Few communities have process for Few communities have process for allocation of scarce EMS resourcesallocation of scarce EMS resources
Off-Site Care Facilitiese.g., Procedure Centers,
Churches, Hotels, Community/Recreation Centers, Warehouses
Home
Clinics and/orPrivate MDs
Treatment/Triage
In-Home Family Care
LTC Facilities
Urgent Care Centers
Neighborhood Emergency Help
CentersMass Dispensing Clinics
Screening Centers
Homecare
Hospitals
Surge Capacity Surge Capacity CoordinationCoordination
Community-Community-Based Based SurgeSurge ClinicsClinics Procedure centers (i.e. dialysis Procedure centers (i.e. dialysis
centers)centers) Long Term Care Facilities (LTCFs)Long Term Care Facilities (LTCFs) HomecareHomecare Family-based careFamily-based care Alternative care sitesAlternative care sites Local / Regional referral / NDMSLocal / Regional referral / NDMS
Clinic surge capacityClinic surge capacity Rural – scant ability to increase capacityRural – scant ability to increase capacity Urban – larger ability to increase Urban – larger ability to increase
capacitycapacity Sub-specialty clinicsSub-specialty clinics Surgical centersSurgical centers
Cancellation of elective appointmentsCancellation of elective appointments Changes in hours / staffingChanges in hours / staffing Receiving referrals from hospital?Receiving referrals from hospital?
CriteriaCriteria SuppliesSupplies
Professional HomecareProfessional Homecare
Homecare agenciesHomecare agencies Social workersSocial workers Durable equipment suppliersDurable equipment suppliers Are agencies prepared to prioritize Are agencies prepared to prioritize
services to accommodate increased services to accommodate increased demands?demands?
Do homecare nurses have other Do homecare nurses have other commitments?commitments?
Family-based careFamily-based care
Will be focus of most care in Will be focus of most care in pandemics and pandemics and
General emergency preparedness General emergency preparedness criticalcritical
Specific informationSpecific information
Alternate Care Sites / Alternate Care Sites / Community ActionCommunity Action Neighborhood Emergency Help CenterNeighborhood Emergency Help Center
Screening and minimal care (for example – Screening and minimal care (for example – early pandemic symptoms requiring anti-early pandemic symptoms requiring anti-virals)virals)
Population-based interventionsPopulation-based interventions Acute Care Center / Off-site care facilityAcute Care Center / Off-site care facility
Non-ambulatory care (may also have role as Non-ambulatory care (may also have role as special needs shelter – NH fire, widespread special needs shelter – NH fire, widespread disaster)disaster)
Hospital overflow –allows hospitals to focus Hospital overflow –allows hospitals to focus on critical careon critical care
Many models – adjacent hospital, regional, Many models – adjacent hospital, regional, self-supporting infrastructure vs. existingself-supporting infrastructure vs. existing
Potential Alternative Potential Alternative Care SitesCare Sites Aircraft hangersAircraft hangers Military facilitiesMilitary facilities ChurchesChurches National Guard National Guard
armoriesarmories Community/Community/
recreation centersrecreation centers Surgical centers / Surgical centers /
medical clinicsmedical clinics Convalescent care Convalescent care
facilitiesfacilities
Sports facilities / Sports facilities / stadiumsstadiums
FairgroundsFairgrounds TrailersTrailers Government Government
buildingsbuildings TentsTents Hotels/motelsHotels/motels WarehousesWarehouses Meeting hallsMeeting halls
Factors to considerFactors to consider Ability to lock Ability to lock
down/Securitydown/Security HVACHVAC Lab/specimen handlingLab/specimen handling LightingLighting LaundryLaundry Loading DockLoading Dock Equipment storageEquipment storage Oxygen delivery Oxygen delivery
capabilitycapability Waste disposalWaste disposal ParkingParking Communications Communications
capabilitycapability
Patient deconPatient decon Door sizeDoor size Pharmacy areasPharmacy areas Electrical power with Electrical power with
backupbackup Proximity to hospitalProximity to hospital Family areasFamily areas Toilets/showers/wasteToilets/showers/waste Food supply / prep areaFood supply / prep area Water supplyWater supply Wired for IT/Internet Wired for IT/Internet
accessaccess Primary and Secondary Primary and Secondary
sitessites Controlled accessControlled access
Kansas Alternative Care
Site Selection Matrix
Air
craf
t Han
gers
Chu
rche
sC
omm
unity
/Rec
reat
ion
Cen
ters
Con
vale
scen
t Car
e
Faci
litie
s
Fair
grou
nds
Gov
ernm
ent B
uild
ings
Hot
els/
Mot
els
Mee
ting
Hal
lsM
ilita
ry F
acili
ties
Nat
iona
l Gua
rd
Arm
orie
sS
ame
Day
Sur
gica
l
Cen
ters
/Clin
ics
Sch
ools Spo
rts
Faci
litie
s/S
tadi
ums
Trai
lers
/Ten
ts
(Mili
tary
/Oth
er)
US
AF
Oth
er
InfrastructureDoor sizes adequate for gurneys 5
Floors
Loading Dock
Parking for staff and visitors
Roof
Toilet facilities/showers (#)
Ventilation
Security
Walls
Infrastructure
What will Happen at the What will Happen at the Acute Care Alternate Sites?Acute Care Alternate Sites? Triage / admission criteriaTriage / admission criteria Level of care – basic nursing, drip Level of care – basic nursing, drip
meds, IVs, NG feedsmeds, IVs, NG feeds MedicationsMedications Documentation / order managementDocumentation / order management LaboratoryLaboratory Food / water / sanitaryFood / water / sanitary Linen and medical waste handlingLinen and medical waste handling Oxygen?Oxygen?
Sample SiteSample Site
Sample SiteSample Site FoodFood RestroomsRestrooms Staff rehab areasStaff rehab areas SecureSecure HVAC system specsHVAC system specs Paging Paging
/messaging /radio/messaging /radio PowerPower Phone, T1 lines, etc.Phone, T1 lines, etc. City owned!City owned!
HEAD
CHAIR HEADCOTA12
2x2 zip-tied to folding 2x2 zip-tied to folding chairs, shim across chairs, shim across toptop
Nails for chart, IV bagNails for chart, IV bag Cards show team Cards show team
color/letter (eg: green color/letter (eg: green A)A)
Other cards show Other cards show pending orders (red = pending orders (red = stat)stat)
Clothespins/rubber Clothespins/rubber bands hold cardsbands hold cards
Ongoing IssuesOngoing Issues Clinic / outpatient care rolesClinic / outpatient care roles
Legal and RegulatoryLegal and Regulatory
ReimbursementReimbursement
Workforce coordination with public healthWorkforce coordination with public health
Credentials / HR issuesCredentials / HR issues
Section 3: Section 3: Selected Surge Selected Surge Situations and Situations and Special TopicsSpecial Topics
Overview – Section 3Overview – Section 3
Event-specificEvent-specific
Behavioral healthBehavioral health
SecuritySecurity
Education and trainingEducation and training
ScenarioScenario 23 year old presents to ED 23 year old presents to ED
– just arrived from Africa– just arrived from Africa Bleeding from everywhere Bleeding from everywhere
– sclera, gums, GI tract, – sclera, gums, GI tract, genitourinary tract, genitourinary tract, bruising skin notedbruising skin noted
Febrile to 101Febrile to 101 Sister who traveled with Sister who traveled with
her is also feeling ill but her is also feeling ill but has no signs yet of her has no signs yet of her sister’s illnesssister’s illness
What do you do?What do you do?
IsolationIsolation SpaceSpace
Triage and screening – location, processTriage and screening – location, process Treatment areas – iso rooms, cohortingTreatment areas – iso rooms, cohorting
Staff - training, call-in, monitor compliance Staff - training, call-in, monitor compliance with PPE, communicationswith PPE, communications
Stuff – antibiotics, anti-virals, analgesia / Stuff – antibiotics, anti-virals, analgesia / sedation, ventilators, PPE suppliessedation, ventilators, PPE supplies
Special – security, communications, family Special – security, communications, family issuesissues
Transport – internal and external issues - Transport – internal and external issues - processprocess
ScenarioScenario Workers at construction Workers at construction
site unearth large jar of site unearth large jar of clear liquid – they pick clear liquid – they pick the jar up and it the jar up and it shattersshatters
Both workers are Both workers are splashed and have splashed and have immediate respiratory immediate respiratory distress as well. Much distress as well. Much of the liquid vaporizes.of the liquid vaporizes.
EMS removes clothing EMS removes clothing and transports as no and transports as no decon available and decon available and respiratory distressrespiratory distress
What do you do?What do you do?
ChemicalChemical
Space – decontamination, triage, Space – decontamination, triage, treatment spacetreatment space
Staff – trained for decontamination, ED Staff – trained for decontamination, ED staff, ICU (if applicable), monitoring of staff, ICU (if applicable), monitoring of PPE use / dutiesPPE use / duties
Stuff – antidotes (particularly atropine Stuff – antidotes (particularly atropine and 2PAM), analgesia, sedation, PPE, and 2PAM), analgesia, sedation, PPE, vents / ICUvents / ICU
Special – decontamination equipment, Special – decontamination equipment, runoff issuesrunoff issues
ScenarioScenario Tornado watch issued at Tornado watch issued at
noon for your citynoon for your city Tornado warning at 4pm Tornado warning at 4pm
– staff and patients – staff and patients shelter in placeshelter in place
Severe damage to large Severe damage to large neighborhood in neighborhood in community, hospital community, hospital multiple windows multiple windows broken, reports of broken, reports of leaking roof in one unit, leaking roof in one unit, electricity out except electricity out except emergency poweremergency power
What do you do?What do you do?
TornadoTornado Command – assess impact on facility / Command – assess impact on facility /
staffstaff Space – triage areas, treatment areas – Space – triage areas, treatment areas –
expand capacity especially outpatientexpand capacity especially outpatient Staff – shift staffingStaff – shift staffing Stuff – Tdap boosters, analgesia, Stuff – Tdap boosters, analgesia,
sedation, local anesthetics, suture trayssedation, local anesthetics, suture trays Special – debris removal, utilities Special – debris removal, utilities
support, staff transportationsupport, staff transportation Transportation – EMS resourcesTransportation – EMS resources
ScenarioScenario Office building explodesOffice building explodes Several persons trapped Several persons trapped
in rubble, at least 2 in rubble, at least 2 fatalities – 2 of injured fatalities – 2 of injured dragged out and dragged out and brought by private car brought by private car to hospitalto hospital
Multiple walking Multiple walking wounded including wounded including some people walking on some people walking on the street / in cars and the street / in cars and hit by debrishit by debris
Few windows broken in Few windows broken in hospital complexhospital complex
Bomb / Blast injuryBomb / Blast injury
Command – facility assessment?Command – facility assessment? Space – triage area, treatment, ORSpace – triage area, treatment, OR Staff – including specialty – ENT, eye, Staff – including specialty – ENT, eye,
surgerysurgery Stuff – analgesia, sedation, Tdap, burn Stuff – analgesia, sedation, Tdap, burn
supplies (adaptic, narcotics, ibuprofen, supplies (adaptic, narcotics, ibuprofen, bacitracin), surgical supplies (suture trays, bacitracin), surgical supplies (suture trays, chest tube)chest tube)
Special – security, behavioral health, Special – security, behavioral health, familyfamily
Other Surge ChallengesOther Surge Challenges
‘‘Upside down triage’Upside down triage’ Family membersFamily members Communications / informationCommunications / information MediaMedia Psychological casualtiesPsychological casualties
IN-HOUSEIN-HOUSEDistressed StaffDistressed Staff
INPATIENTINPATIENTDistressed InpatientsDistressed Inpatients Family MembersFamily Membersof Inpatientsof Inpatients
INCOMINGINCOMING
Behavioral Health Surge Behavioral Health Surge DemandsDemands
MediaMedia VolunteersVolunteers OnlookersOnlookers
PsychologicalPsychologicalCasualtiesCasualties
EMS-EMS-ProcessedProcessed
MedicalMedicalCasualtiesCasualties
Self-TransportedSelf-TransportedMedical CasualtiesMedical Casualties
Bystanders orBystanders orFamilyFamily
Members,Members,Friends,Friends,
Co-workersCo-workersof Incomingof IncomingCasualtiesCasualties
Family MembersFamily MembersSearchingSearchingfor Missingfor MissingLoved OnesLoved Ones
Injured,Injured,Exposed,Exposed,
DistressedDistressedDisaster/Disaster/
EmergencyEmergencyWorkersWorkers
Behavioral Health SurgeBehavioral Health Surge SortingSorting
Triage psychological (or likely) to Triage psychological (or likely) to observation areaobservation area
SupportingSupporting Quiet areaQuiet area Food and liquidsFood and liquids Family support area as wellFamily support area as well
ServicesServices Chaplaincy, social work, Chaplaincy, social work,
psychology/psychiatry, CISM, psychological psychology/psychiatry, CISM, psychological first aidfirst aid
Observe, screen, refer as neededObserve, screen, refer as needed
AftereffectsAftereffects
Continued high ER Continued high ER and clinic volumesand clinic volumes
Psychological Psychological stressorsstressors
Unique hazards Unique hazards may affect health may affect health after the eventafter the event
NYC post 9-11-01NYC post 9-11-01
22.5% increase in asthma over 5-9 22.5% increase in asthma over 5-9 weeks younger patients, 44% > 54 weeks younger patients, 44% > 54 yrsyrs
75% in random phone survey 75% in random phone survey reported adverse psychological reported adverse psychological effectseffects
MMWR Sept. 6, 2002MMWR Sept. 6, 2002
SecuritySecurity
LockdownLockdown Ingress / egress controlIngress / egress control Staff:Staff:
HospitalHospital ContractContract Public SafetyPublic Safety Community sourcesCommunity sources
Policies and procedures – weapons, Policies and procedures – weapons, crowd control, use of forcecrowd control, use of force
Education and TrainingEducation and Training
Hospital Incident Command TrainingHospital Incident Command Training Just-in-Time TrainingJust-in-Time Training DrillsDrills
TabletopTabletop FunctionalFunctional
What do I do now?What do I do now?
Next StepsNext Steps ReviewReview
Your Emergency Operations PlanYour Emergency Operations Plan Incorporate Incident CommandIncorporate Incident Command Clearly define what a hospital employee will DOClearly define what a hospital employee will DO Have current job actions sheets and reporting Have current job actions sheets and reporting
formsforms Request more training in Incident Command if Request more training in Incident Command if
neededneeded Imbed Incident Command in daily operations Imbed Incident Command in daily operations
Next Steps to SurgeNext Steps to Surge
Define your Surge Capacity PartnersDefine your Surge Capacity Partners Make sure they know what you expect Make sure they know what you expect
of them.of them. Identify federal assetsIdentify federal assets Acquire the needed bed-tracking Acquire the needed bed-tracking
program & trainingprogram & training Create a Pre-surge planCreate a Pre-surge plan
If time allows: If time allows:
Surge “Capacity”Surge “Capacity”
SpaceSpace Evaluate your physical facilityEvaluate your physical facility
Space for cots, family, media, staff respite Space for cots, family, media, staff respite BH …BH …
Evaluate near-by external facilitiesEvaluate near-by external facilities Create guidelines for early dismissalsCreate guidelines for early dismissals
Surging PersonnelSurging Personnel
StaffStaff Determine ways to reallocate internal Determine ways to reallocate internal
staff rolesstaff roles Determine external staffing optionsDetermine external staffing options
Determine process for assigning Determine process for assigning mentors/preceptorsmentors/preceptors
Plan Staff ExtendersPlan Staff Extenders Just-In-Time TrainingJust-In-Time Training
Considering SuppliesConsidering Supplies
StuffStuff Create a plan for a quick inventoryCreate a plan for a quick inventory
PPEPPE General Patient Care Supplies – include General Patient Care Supplies – include
medicationsmedications Specialty Patient SuppliesSpecialty Patient Supplies Support Supplies Support Supplies
Food, water, office, communicationFood, water, office, communication
Create a plan to begin stockpiling Create a plan to begin stockpiling
Planning for the T’sPlanning for the T’s
TriageTriage Train in Mass-Casualty TriageTrain in Mass-Casualty Triage Plan triage areas, internal and externalPlan triage areas, internal and external Locate Vests and TagsLocate Vests and Tags
TreatmentTreatment Discuss and plan for temporary Discuss and plan for temporary
treatment of non-life-threatening treatment of non-life-threatening injuries.injuries.
Discuss alternative record-keeping Discuss alternative record-keeping
TransportationTransportation InternalInternal
Determine number and location of Determine number and location of wheelchairs/gurneyswheelchairs/gurneys
Plan for alternate modes of transportationPlan for alternate modes of transportation ExternalExternal
Know your local transport resourcesKnow your local transport resources Plan for alternate modes of transportationPlan for alternate modes of transportation
Community Based SurgeCommunity Based Surge
Coordinate with local Public HealthCoordinate with local Public Health Determine your roleDetermine your role Identify existing plansIdentify existing plans
Revisit Parking Lot Revisit Parking Lot IssuesIssues
Please fill out your evaluations Please fill out your evaluations and and
Self AssessmentSelf Assessment
Thank you for Thank you for Coming!Coming!